<form id="edit-form" class="form-horizontal" role="form" data-toggle="validator" method="POST" action="">

    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Name')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-name" class="form-control" name="row[name]" type="text" value="{$row.name}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Guangdong')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-guangdong" class="form-control" name="row[guangdong]" type="text" value="{$row.guangdong}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Jiangsu')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-jiangsu" class="form-control" name="row[jiangsu]" type="text" value="{$row.jiangsu}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Chongqing')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-chongqing" class="form-control" name="row[chongqing]" type="text" value="{$row.chongqing}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Henan')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-henan" class="form-control" name="row[henan]" type="text" value="{$row.henan}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Tianjin')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-tianjin" class="form-control" name="row[tianjin]" type="text" value="{$row.tianjin}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Shanghai')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-shanghai" class="form-control" name="row[shanghai]" type="text" value="{$row.shanghai}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Anhui')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-anhui" class="form-control" name="row[anhui]" type="text" value="{$row.anhui}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Shanxi')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-shanxi" class="form-control" name="row[shanxi]" type="text" value="{$row.shanxi}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Zhejiang')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-zhejiang" class="form-control" name="row[zhejiang]" type="text" value="{$row.zhejiang}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Jilin')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-jilin" class="form-control" name="row[jilin]" type="text" value="{$row.jilin}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Rate')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-rate" class="form-control" name="row[rate]" type="text" value="{$row.rate}">
        </div>
    </div>
    <div class="form-group layer-footer">
        <label class="control-label col-xs-12 col-sm-2"></label>
        <div class="col-xs-12 col-sm-8">
            <button type="submit" class="btn btn-success btn-embossed disabled">{:__('OK')}</button>
            <button type="reset" class="btn btn-default btn-embossed">{:__('Reset')}</button>
        </div>
    </div>
</form>
